Reactions 1222 - 4 Oct 2008

SBupivacaine/mepivacaine

Neck cellulitis, abscess and mediastinitis followingcontinuous interscalene brachial plexus block: casereport

Neck cellulitis, abscess and mediastinitis occurred in a61-year-old man following interscalene brachial plexus blockwith bupivacaine and mepivacaine for shoulder surgery.

An interscalene catheter was placed prior to generalanaesthesia induction with propofol, fentanyl and isoflurane.The man received 20mL of 0.5% bupivacaine and 20mL of 2%mepivacaine, injected via the catheter. He receivedcefamandole during surgery. After surgery lasting 70 minutes,he received postoperative analgesia with continuous infusionof bupivacaine 0.25% at 5mL/hour; pump filling required6 × 20mL bottles of bupivacaine 0.5%, and 120mL of saline.The bupivacaine infusion lasted for 39 hours. The day aftersurgery, he reported neck pain.

The man received nalbuphine. The analgesic block was notfully effective. The next day, when the catheter was removed,local neck pain, erythema and induration were noted. Hereceived pristinamycin and frozen dressings. He wasdischarged, but re-admitted 3 days later with neck oedema,fever, fatigue and worsening erythema. Investigations revealedthe following: HR 120 beats/min, temperature of 39.8 °C,respiratory rate 21 beats/min, BP 120/80mm Hg, leucocytecount of 27 × 109/L and C-reactive protein level 250 mg/L. Aneck ultrasound and CT scan showed sternocleidomastoid andinterscalene muscle abscess and cellulitis, and acutemediastinitis. He underwent surgical drainage of his neck andmediastinum; cultures revealed Staphylococcus aureus. His3-week hospital stay was complicated by pulmonaryembolism secondary to thrombosis and C8-T1 neuropathy. Hereceived antibiotics for 2 months, and a subsequent CT scandid not show mediastinitis or cellulitis; his neuropathyresolved within 4 months.

Author comment: "[N]eck cellulitis and abscess mostlikely resulted from catheter colonization or local anestheticcontamination with subsequent extension from theinterscalene space to the mediastinum. This case emphasizesthe importance of strict aseptic conditions during needlepuncture, catheter insertion, and management, includinghandling of local anesthetic."Capdevila X, et al. Acute neck cellulitis and mediastinitis complicating acontinuous interscalene block. Anesthesia and Analgesia 107: 1419-1421, No. 4,Oct 2008 - France 801124136

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Reactions 4 Oct 2008 No. 12220114-9954/10/1222-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved